Subspecialty Surgery Flashcards
How does esophageal atresia present?
Presents as excess salivation, choking spells, coiling NG tube, and often a TE fistula
Tx surgical repair
What is VACTERL syndrome?
Vertebral Anal atresia Cardiac TracheoEsophageal fistula Esophageal atresia Renal Limbs (radius)
How do you manage anal atresia?
High rectal pouch –> colostomy then delayed repair, low rectal pouch –> repair, if anofistula present –> delay repair since further growth may correct condition
How does a congenital diaphragmatic hernia present?
Presents as RDS due to hypoplastic left lung
Dx: CXR shows bowel in left chest, tx intubation with low pressure ventilation
What is gastroschisis?
midline hernia to left of umbilical cord tearing through peritoneum
tx: closure if small, silo if large, and TPN for a month since GI doesn’t work
What is an omphalocele?
Midline hernia through the cord with peritoneal covering; tx closure if small, silo if large
What does biliary vomiting indicate?
Indicates SBO distal to ampulla of Vater; DDx duodenal atresia, intestinal atresia, annular pancreas, or malrotation
How does malrotation present?
Presents as biliary vomiting and double-bubble on X ray; dx contrast enema or upper GI study, tx emergency surgical correction
How does intestinal atresia present?
Presents as biliary vomiting and multiple air-fluid levels on X-ray, aka apple-peel atresia due to vascular accident in utero
How does necrotizing enterocolitis present?
Presents as feeding intolerance, abd distention, and decreased platelets in premies; tx NPO, IVF, TPN, IV abx –> surgical repair if signs of intestinal necrosis/perforation present
How does pyloric stenosis present?
Presents as non-bilious projectile vomiting in first-born boys; dx palpable epigastric olive tx rehydration and pyloromyotomy
How does biliary atresia present?
Presents as progressive jaundice in a 1-2 month old due to lack of CBD; Dx HIDA scan + phenobarbital (to stimulate GB contraction), Tx liver transplant
How does Hirschsprung’s disease present?
Presents as chronic constipation due to lack of nerves in distal colon, rectal exam can decompress bowel; dx X ray shows distended proximal colon, tx surgical pull-through
How does intussusception present?
Presents as colicky abd pain that lasts 1 minute then resolves, and currant jelly stools; dx/tx barium or air enema
How does child abuse present?
Presents as retinal hemorrhages, SDH, multiple healed fx, and scalding burns; call child protective services
How does Meckel’s diverticulum present?
Presents as LGIB in a child, dx technetium uptake for ectopic gastric mucosa
How do vascular rings present?
Stridor, RDS, crowing respiration, and dysphagia in an infant due to compression of trachea and esophagus; dx barium swallow and bronchoscopy, tx surgical correction
How does an ASD present?
Presents as low-grade systolic murmur, fixed S2, and frequent colds; dx echo, tx surgery
How does a VSD present?
Presents as pansystolic harsh-sounding murmur with failure to thrive; dx echo, tx surgery
How does a PDA present?
Presents with machinery-like murmur, often seen with congenital rubella syndrome; dx echo, tx indomethacin or surgery
How does Tetralogy of Fallot present?
Presents as cyanosis and clubbing in a five y/o child who squats for relief; px determined by degree of pulmonary stenosis, dx echo shows RVH, tx surgery
How does transposition of the great vessels present?
Presents as life-threatening cyanosis in a newborn; dx echo, tx surgery
What is strabismus?
Misaligned eyes due to uncoordinated extraocular muscles; tx surgical extraocular muscle manipulation to prevent ambylopia
What is amblyopia?
Vision impairment usually due to strabismus in kids
tx eyepatch the good eye to develop the impaired one
How does retinoblastoma present?
Presents as a leukocoria in a baby
Tx surgical enucleation
How does retinal detachment present?
Presents as flashes and floaters, and a dark curtain being pulled down over the eye; tx emergency laser “spot welding”
What is amaurosis fugax?
Emboli from carotid travels to retina causing transient blindness
dx fundoscopic exam reveals hollenhorst plaque, a bright shiny spot in a retinal artery
How does an embolic occlusion of the renal artery present?
Presents as a sudden unilateral loss of vision; tx breathe into paper bag and repeatedly press on eye to shake clot into a more distal branch of retinal artery
What is a tyroglossal duct cyst?
Remnant of thyroglossal duct as a mobile midline neck mass
Dx at 1-2 years old due to neck fat
Tx Sistrunk operation (take out cyst, trunk, and medial portion of hyoid bone)
What is a branchial cleft cyst?
Lateral mass at anterior edge of SCM, may have a small opening and blind tract
What is a cystic hygroma?
Dilated lymphatic duct at base of neck, common in Turner syndrome, get CT scan to find extent of mass before surgical removal
How do lymphomas present?
Present with multiple swollen LN, fever, and night sweats; get excisional biopsy then Tx chemo
How does head/neck SCC present?
Presents as persistent hoarseness, painless ulcer in the floor of mouth, or unilateral earache; risk factors are EtOH, smoking, and AIDS
How do you manage SCC of the head/neck?
Get triple endoscopy to look for primary tumor–> biopsy tumor–> CT scan to determine stage; tx resection, radical neck dissection, cisplatin-based chemo
How does an acoustic neuroma present?
presents as unilateral deafness due to Schwann cell proliferation on CN VIII
How does a facial nerve tumor present?
Presents as gradual-onset unilateral facial paralysis (sudden-onset Bell’s palsy)
How does a parotid tumor present?
Masses around angle of mandible, two types– pleomorphic adenomas (benign, painless) and mucoepidermoid carcinomas (malignant, painful)
Get a FNA or formal superficial parotidectomy
What is Ludwig angina?
Abscess in floor of mouth due to tooth infection, tx is I and D and tracheostomy
How does cavernous sinus thrombosis present?
Presents as diplopia in a patient with sinusitis due to nerve injury
tx with antibiotics, CT scan, and drainage of abscess
What do you think of when you see epistaxis in teens? In the elderly?
Teens: either cocaine abuse and septal perforation (requires packing) or juvenile nasopharyngeal angiofibroma (surgical resection)
Elderly: due to HTN; requires packing, BP control, and often surgical ligation of vessels
How is vertigo due to the inner ear different from vertigo due to the brain?
Inner ear: “room is spinning” tx meclizine, phenergan, or diazepam
Brain: “patient is spinning, room is stable”, do a neuro workup
What is a TIA?
Brief neurologic deficit that fully resolves within 24 hours; due to thromboembolus from internal carotid arteries
Manage with carotid duplex, then aspirin and elective CEA
What is an ischemic stroke?
A neurologic deficit that doesn’t resolve within 24 hours due to thromboembolus from internal carotid arteries
Tx t-PA within three hours, otherwise observe and rehab
What is a hemorrhagic stroke?
Severe headache and neurologic deficit that doesn’t resolve within 24 hours in uncontrolled HTN; Dx CT scan, Tx rehab and control of HTN
What is a SAH?
“Worst headache of my life” due to rupture of Charcot-Bouchard aneurysm in lenticulostriate arteries
dx: CT scan to confirm SAH, then arteriogram to locate aneurysm, the surgical clipping
How does a CNS abscess present?
Presents as space-occupying lesions but short onset (weeks) with nearby infections (otitis media, mastoiditis); get CT scan then resect
How do CNS tumors present?
Presents as space-occupying lesions and progressive headache over months; get MRI then resect (give mannitol, hyperventilate, and high-dose steroids while waiting)
How do frontal lobe tumors present?
Present as disinhibition, anosmia (CNI), ipsilateral blindness (CNII), and contralateral papilledema
How does a prolactinoma present?
Presents as amenorrhea and galactorrhea in a young woman, consider possibility of MEN1 syndrome, tx with bromocriptine
How does a craniopharyngioma present?
Presents as GH deficit and bitemporal hemianopsia in a kid
Dx calcified sella turcica
How does acromegaly present?
Presents as huge hands, feet, tongue, and jaws in a tall man due to increase in GH; dx get somatomedin C levels and MRI, then resection
How does Nelson syndrome present?
Presents as bitemporal hemianopsia and hyperpigmentation in an adult due to pituitary microadenomas that grew to full size; dx MRI then Tx surgical resection
How does pituitary apoplexy present?
Presents with typical pituitary adenoma sx, then sudden onset headache and CNS sx due to bleeding into tumor; dx MRI then emergent steroid replacement
How does a pinealoma present?
Presents as loss of upper gaze and “sunset eyes” due to compression of vertical gaze center in superior colliculi
How do spinal cord tumors present?
Present as back pain in someone who has been treated for other cancers
Dx MRI
Tx neurosurgical decompression
How do brain tumors in kids present?
Present as cerebellar sx and headaches relieved by knee-chest position
Due to posterior fossa lesions
Dx MRI, Tx resection
How does a neurogenic claudication present?
Presents with pain on exertion and relief with rest, but pain is position-dependent and pulses are intact; dx MRI tx neurosurgical decompression
How does a trigeminal neuralgia present?
Severe facial pain lasting 60 seconds; dx MRI to rule out organic cause, then tx with anti-convulsants (radiofrequency ablation as backup)
How does reflex sympathetic dystrophy present?
Presents as severe pain months after a crush injury with sympathetic overload
Dx sympathetic block
Tx sympathectomy
How does testicular torsion present?
Presents as severe testicular pain and “high riding testicle with horizontal lie” due to twisting of the cord; tx emergent surgical detorsion, then orchiopexy
How does epididymitis present?
Presents like testicular torsion but with fever, pyuria, and cord is also tender; dx U/S to rule out torsion, then antibiotics
How does an obstructive UTI present?
Presents as sepsis (fever, chills, flank pain) in someone passing a kidney stone; surgical emergency that requires immediate decompression (stent or perc nephrostomy) in addition to IV antibiotics
How does prostatitis present?
Presents as fever, chills, dysuria, back pain, and tender prostate on rectal exam; give antibiotics and don’t do any more rectal exams
How do posterior urethral valves present?
Present as anuria in a newborn boy; catheterize to empty bladder, then dx voiding cystourethrogram
tx resection
How does hypospadias present?
Presents as urethral opening on ventral side of penis, never circumcise since prepuce is needed for surgical correction
What is epispadias?
Urethral opening is on the dorsal penis
How does VUR present?
Presents as dysuria, fever, chills, and flank pain in kids due to ascending UTI; give antibiotics and dx IV pyelo and voiding cystogram to look for reflux
longterm abx until child “grows out of it”
How does a low implantation of the ureter present?
Asymptomatic in boys, “wet with urine all the time” in girls because ureter drips into vagina instead of bladder
dx PE or IV pyelo
How does a uteropelvic obstruction present?
Usually asymptomatic, but presents with colicky pain with large diuresis
What are the urologic cancers?
renal cell carcinoma: hematuria, flank mass/pain, and paraneoplastic syndromes (PAPER– PTHrP, ACTH, prolactin, EPO, renin)
bladder transitional cell carcinoma: presents as painless hematuria in smokers; get IV pyelo and cystoscopy, high rate of local recurrence
prostatic cancer: asymptomatic, rock-hard nodule on rectal exam; get U/S guided needle biopsy then TURP or radiation therapy
How does testicular cancer present?
Presents as painless testicular mass that doesn’t transilluminate; get radical orchiectomy with biopsy, then f/u with aFP or BHCG for recurrence
tx cisplatin or radiation if metastatic
How does BPH present?
presents as dribbling, nocturia, and difficulty voiding in an old man; put in Foley for three days, and tx with alpha blockers, 5aR blockers +/- surgical resection
How does stress incontinence present?
Presents as urine leaking with abdominal pressure due to weakened pelvic floor in a multigravid woman; tx surgical repair of pelvic floor
How do kidney stones present?
Presents as colicky flank pain and hematuria +/- radiation to the inner thigh
Dx plain X rays
Tx analgesics, fluids, and observation
What is the only contraindication to a transplant donor?
HIV status (unless donating to an HIV patient)
What is hyperacute rejection?
Performed ab’s against donor organ causes vascular thrombosis within minutes; never seen since type-and-cross prevents this from happening
What is acute rejection?
HLA mismatch causes macrophage attack on donor tissue with lymphocytic infiltrate, confirmed by biopsy
What are the signs of liver rejection?
Indicated by elevated LFTs, first step is to get U/S and Doppler to rule out biliary obstruction and vascular thrombosis
What is chronic rejection?
Gradual deterioration of organ function due to polymorphisms, irreversible and no tx available
